453-04-7155-m5
DECISION AND ORDER James Wetz, D.C. (Provider), appealed the decision of an Independent Review Organization (IRO) upholding the denial of reimbursement for a physical therapy program rendered to ___ (Claimant) from February 19, 2003, through April 9, 2003. In this decision, the Administrative Law Judge (ALJ) finds that Provider failed to meet its burden of […]
453-04-6004-m5
DECISION AND ORDER This case is a dispute over whether Insurance Company of the State of PA., (Carrier) should reimburse Highpoint Pharmacy (Respondent) for prescription medications provided to an injured worker (Claimant) from February 17, 2003, until May 2, 2003, in the amount of $2,784.19. The Administrative Law Judge (ALJ) concludes that Petitioner has not […]
453-04-5923-m5
DECISION AND ORDER Brian Randall, D.C., (Petitioner) appealed the decision of the Texas Workers’ Compensation Commission’s (Commission) Medical Review Division (MRD) to adopt the decision of its designee, an independent review organization (IRO), in MR Docket No. M5-04-1230-01. The decision upheld American Casualty Company of Reading, PA.’s (Carrier) denial of reimbursement for services provided a […]
453-04-7290-m5
DECISION AND ORDER Petitioner, South Austin Therapy Group (Provider) appealed the Findings and Decision of the Medical Review Division (MRD) of the Texas Workers’ Compensation Commission (TWCC) denying reimbursement from Highlands Underwriters Insurance Company (Carrier) for medical services rendered to an injured worker (Claimant). Provider disputes the conclusion of the Independent Review Organization (IRO) that […]
453-04-6408-m5
DECISION AND ORDER Texas Mutual Insurance Company (Carrier) challenges an independent review organization (IRO) decision granting reimbursement to Brett M. Downey, D.C. (Provider) for therapeutic exercises, range-of-motion measurements, and office visits provided to an injured worker (Claimant). The Administrative Law Judge (ALJ) concludes most of the disputed services were shown not to be medically necessary […]
453-04-2057-m5
DECISION AND ORDER I. DISCUSSION On December 14, 2004, Texas Mutual Insurance Company (TMIC), Petitioner, requested a hearing to contest the Findings and Decision of the Texas Workers’ Compensation Commission (Commission) acting through Medical Review of Texas, Inc., an Independent Review Organization (IRO).[1] By letter issued on November 13, 2003, the IRO disagreed with TMIC’s […]
453-04-6343-m5
DECISION AND ORDER Florists Mutual Insurance Company (Carrier) challenged the decision of the Medical Review Division of the Texas Workers’ Compensation Commission (MRD/Commission) ordering it to reimburse Healthtrust, LLC (Provider), for a pain management program that Provider administered to ___ (Claimant) from December 2, 2002, through February 19, 2003. Carrier also appealed the MRD’s denial, […]
453-04-4717-m5
DECISION AND ORDER This case is an appeal by Dana J. Santelli, D.C. (Provider), from a decision of an independent review organization (IRO) on behalf of the Texas Workers’ Compensation Commission (Commission) in a dispute regarding medical necessity for chiropractic treatment. The IRO found that the insurer, American Home Assurance Company (Carrier), properly denied reimbursement […]
453-04-5734-m5
DECISION AND ORDER Claimant ___ developed acute right forearm and wrist pain on ___. He was diagnosed with right carpal tunnel syndrome and deQuervain’s tenosynovitis. Following surgery, ___ received 41 sessions of physical therapy from March 12 to May 29, 2002. The carrier, Hammerman & Gainer LM Insurance Corporation (Carrier), paid for some of the […]
453-04-6504-m5
DECISION AND ORDER This case is a dispute over whether Fidelity & Guaranty Insurance Company (Carrier) should reimburse VONO (Petitioner) $415.20 for a prescription medication. The medical necessity of the medication is the only issue to be resolved. The Administrative Law Judge (ALJ) concludes that Petitioner met its burden of proving the medication was medically […]